HospitalInspections.org

Based on interviews with hospital staff, the review of policies and procedures and a document titled, "The patient at Salem Health," revised 03/2012, it was determined that the hospital failed to provide a written notice of its decision, that contained the four required elements: name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. A policy titled "Resolution of Patient Complaints/Grievances," effective 12/2012 was reviewed and reflected "A. The assigned manager shall send a written response to the patient or authorized representative raising the initial grievance within seven (7) business days (Monday-Friday) of receipt of the grievance. B. In the written response...the letter must provide adequate information to address the following: 1. An apology; 2. The name of the hospital contact person; 3. The steps taken on behalf of the patient to investigate the complaint - although the written response is not required to have an exhaustive explanation of every action taken to investigate and resolve the grievance; 4. The results of the investigation and grievance process; 5. The date the grievance was completed; and 6. A decision regarding a claim..."

2. The grievance letter that was sent to Patient #5 was reviewed on 01/03/2013 at 1130. The letter was signed by the Nurse Manager of Labor & Delivery and by the certified nurse midwife who delivered the baby. It was determined that the letter did not reflect all four elements identified in the Administrative Housewide policy or required by this regulation. The letter lacked the steps taken on behalf of the patient to investigate the grievance.

3. An interview was conducted with the Director of Service Excellence on 01/03/2013 at 1330. He/she acknowledged that the written notice sent to Patient #5 did not include all four elements required by this regulation.